The Case of Mr. JR

Mr. J.R. is a 64-year-old Mexican American former car mechanic. An otherwise healthy appearing man at close to six feet and 155 lbs., he was functionally unemployable at his trade because of his peripheral vascular disease, which had already taken away his left leg below the knee. With the use of his prosthesis he was able to get around and do odd jobs as a handyman.

He also suffered from diabetes, which had only been moderately controlled. He knew that his diabetes could improve if he began to use insulin, however he could not bring himself to even consider it. He felt “if I start this insulin, I know that I’ll end up on dialysis like my mother”. “She suffered so much!” he lamented. Despite his decision not to begin insulin, Mr. J.R. was compliant with his medications and office visits.

One morning he arrived at the clinic and informed his physician that he had developed an ulcer to his toe. Sure enough, he had developed a small but ominous blister to the right second toe. It was only about one quarter of an inch but, unfortunately, Mr. J.R.’s foot showed the classic signs of poor circulation: absent pulses to the feet, paper thin skin, and cold feet.

Although it was not an emergency, this blister was an urgent issue which would need to be attended by a team of specialists including a vascular surgeon to improve the circulation to his foot, a podiatrist to prevent any further extension of the blister, and very possibly physical therapy and rehabilitation to recover from any surgery. His wife’s immediate response was “Doctor. Can’t we just cut the toe off now?” Mr. J.R. concurred. They were assured that such drastic steps were not necessary at this point if a team approach was implemented soon.

Unfortunately, the couple had no resources. At 64 years and two months of age, Medicare was at least ten months away. The next reasonable option was to utilize the local university medical center, one of the “Top 50” in the nation. They were just three miles away from the clinic. However, Mr. J.R. lived just across the county line.

He could only be admitted at this medical center if he arrived through the emergency room with a serious medical or surgical condition. In his county of residence, funds were very limited, with no orthopedic surgeon providing care at the local county hospital. Seeking a private consultation would require a high fee, with payment to any admitting hospital being next to impossible because of costs.

Mr. J.R. was followed weekly at the clinic with aggressive medical therapy. The distal phalanx of his toe ulcerated through the blister by one quarter of an inch and healed by the tissue of his toe constricting over the bone. He remained stable with no evidence of spreading infection. During the three months it took to heal the ulcer, he had instructions to go to the hospital if he ever had swelling, pain, or fever; fortunately he never did.

Mr. J.R. eventually received his Medicare. Within the year of receiving his medical coverage, he developed an infection of the foot with resulting amputation, had a stroke affecting his speech, and was eventually admitted to a nursing home for skilled nursing care.

Questions for Discussion

1. What issues of access to health care affected the health outcomes for Mr. J.R and his family?

2. How might insulin therapy have changed the outcome?

3. Who is the decision maker?

4. What might have been done to increase the acceptability of insulin for Mr. J. R.?